HomeMy WebLinkAboutMiscellaneous - 69 FERNVIEW AVENUE 4/30/2018 J 69 FERNVIEW AVENUE U-10
210/453.1-0069-0010.C
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Date.. .b. �. ..................
TOWN OF NORTH ANDOVER
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PERMIT FOR WIRING
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This certifies that7)7 .!
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has permission to perform m �M
wiring the building of.............
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at ..1,, 4 � !�N1 ,North Andover,Mas .
............ .........................................
Fee..... � .......Lic.No.
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"� �� E ECTRICAL NSPECTOR
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Commonwealth of Massachusetts Official Use Onl
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C),527 12.00
(PLEASE PRINT ININK OR TYPE ALL NFORMATION) Date:—V/ Z
City or Town of. NORTH ANDOVER To the Ins ector f Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) (;1 10
Owner or Tenant 6 t`1-v .1✓ Telephone No.
Owner's Address =1 GtfG1� Jalell /1 c/
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: hr`l�/h 'l
V-145 f &P c.e 4oad Fe, ,e p
Completion of thefollowing table maybe waived by the Inspector of Wires.
No.of Total
No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
• Above In- o.o Emergency Lighting
No.of Luminaires Swimming Pool rnd. rnd. ❑ Battely Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Detection and
No.of Switches No.of Gas Burners Initiatin Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers HeatPump Number Tons KW No.of Self-Contained 'T
P Totals: - •������ ��• � Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW tData
Conne Municipal
❑ Other
No.of Dryers Heating Appliances KWy Systems:Y
of Devices or Equivalent
No.of Water T No.of No.ofiring:
Heaters Si ns Ballastsof Devices or Equivalent
Bathtubs No.of Motors Total BF Telecommunications Wiring:
No.Hydromassage No.of Devices or Equivalent
OTHER:
Attach additional detail if desired tor of or as required by the InspecYVTres.
Estimated Value of Electrical Wo (�;O (When required by municipal policy.)
Work to Start: 10-7r Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVER AG : Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liabili insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such cov age is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,under tl . s anddpenalties ofper. ry,that the information on this application is true and complete. _
FIRM NAME: GrrZ < LTC.NO.:
Licensee: Signature LTC.NO.:
(If applic Ze a ter "e empt"in the license number line.) j �� ( Bus.Tel.No.:
Address: �- heVty a l a✓�c '1l M� Alt.Tel.No.:
*Per M.G.Lc. 14 ,s.57-61,security work requires Department of Public Safety"S"License: Lie.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent PERMIT FEE. $
Signature Telephone No.
• , i
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the 1
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed I
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass 0 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments: 1
i
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date: ,
ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.) ❑ 4
Inspectors Comments:
Inspectors Signature- $ ,, Date:
FINAL INSPECTION: wig J
Pass Failed Re-Inspection Required($.) ❑
Inspectors Comments:
-v
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
fM Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
UM www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ✓1<��'� �G Lc,Ce!/1so
d �L`l:`G�aLIrGL�
a —V
Address: �re4 W41,L a,& °
City/State/Zip: 01� ( Phone#: _7!6� f 721 32- �
Are you an employer?Check the appropriate box: I Type of project(required):
L❑ m a employer with 4. ❑ I am a general contractor and I 6
F1 New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insiu-ance required.]t employees. [No workers'
comp.insurance required.] 13.❑Other
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
!formation.
isurance Company Name:
olicy#or Self-ins.Lic.#: Expiration Date:
ib Site Address: City/State/Zip:
.ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ne u�to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
F up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ivestigations of the DIA for insurance coverage verification.
do hereby certify under the pains and enaltie perjury that the information provided is tand correct.
i nature: Date: 1�abov ru C
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have `
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the 1
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-"SAFE
evised 5-26-05 Fax#617-727-7749
www mace CFnv/rlia
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Date. .V?2.1/x . . . .... .
pF NpRTM ,1'
3? TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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SACHUSEt
This certifies that . . . . .. . . . ' . .
has permission for,gas installation . . . H . . . . . . . . . . . . . . . . . . . .
in the buildings of . . ., /k!. . :!. . . . . . . . . . . . . . . . .
at . . . . . . . . .. North Andover, Mass.
Fee.2.0 . Lic. No..959. `. . . `-yyI . . . . . .
l�GAS INSPECTW
Check#
72 ' 8
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MASSACHUSETTS UNIFbRMAPPUCATON FOR PFRMU TO DO GAS F rr]NG
(Type or print) Date
NORTH ANDOVER,MASSACHUSETTS
Building Locations D/>—46 F a j Ld/
Permit# e7 Z 1-
Owner's
Owner's Namej�Al �y ount$
New / e��
Renovation Replacement Plans Submitted
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SUB-BASEMENT
B A S E M ENT +
IST. FLOOR
2ND. FLOOR
r3RD . FLOOR
4TH . FLOOR
TH. FLOOR
1,118
TH . FLOOR
7TH . F L 0 0 R
.TH . FLOOR
(Print or type ; y — 'J
Name _j j eck one: Certificate Installing Company
Ili ti't 1 j nn Corp.
Address 0 ( 65 —
.S
�`'__ Partner.
m
usessTelephone_ -Z>� g--,p ("�
(� i m/Co.
Name of Licensed Plumber or Gas Fitter V+1N `)
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. yes �!
If you have checked Yes,please indicate the type coverage by checking the appropriate box. No�
Liability insurance policy 13 Other type of indemnity
Bond 1
Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Check one:
Owner 1 Agent
hereby certify that ail of the details and information I have submitted(or entered)in above appli n are true and accurate to the
best of my knowledge and that all plumbing work and in ons performed under Permit Is ed for is application will be in
compliance with all pertinent provisions of the Massac setts tate G d d Cha 14 f General Laws. .
BY Signature of Lic ed Plumber Or Gas Fitter
Title Plumber :47
�c�t�y
lCivrown 1:3Gas Fitter License Number
Master
APPROVED(OFFICE USE ONLY) Journeyman
Date.
HORTM TOWN OF NORTH ANDOVER
- PERMIT FOR,PILUMBING
1
,SSACNUSE�
This certifies that . . .���!. ! .�. . . .r �`_. �. `�! . . . . . . . . . . . . . .
has permission to perform . . . . . .l' . _ . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of . A. .7. . . . . . . . . . . . . . . . .
at. .6�� �. . . t'.['I?!`. .►_ !^-, , , , , . . ., North Andover, Mass.
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Fee. .v . . . .Lic. No..52 r- . . . . . . . ..
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cl PLUMBING INSPECTOR
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HoaTH TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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SACeHUSES�
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This certifies that . . . . . . . . . . . . . . . . . . .
has permission for gas installation . ::: . . . . . . . . . . . . . . .
in the buildings of
at . .�. . ' �:! } -•- - `: ` . 9. . ., North Andover, Mass.
Fee/5. . . . . . . Lic. No�: j. . . . . . . . . . . . . . . . . . . . .
GASINS OR
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING /5
(Print or Type)
Mass. Date a 19 Permit #
Building Location (� ! � h 1/�e�,J V� % Owner's Name ll GAJ/ 16a.-✓! 7 h(?49
A) ✓Q4, w 0 ( S Type of Occupancy
New ❑ Renovation ❑ Replacement Plans Submitted: Yesp No p
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SUB—BSMT.
BASEMENT
ISTFLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name �2(,A rZ T A . 7-AM MA T rV0 Check one: Certificate
Address 30 nAH Ivn a ty L J. ❑ Corporation
(11 7 N U E rJ r)1 rl U (k p Partnership
Business Telephone_ 6,5�Z -(7 9'7 ( 2/rm/Co
Name of Licensed Plumber or Gas Fitter A01BE P TA• 5Amm tqTA r —
INSURANCE COVERAGE:
I have a current ability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes [�d' No ❑
If you have checked Les, please indicate the type coverage by checking the appropriate box
A liability insurance policy '
Other type of indemnity❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner'sAgent Owner❑ Agent [I
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the 106M)WI—Oued for this application vA be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws.
T of License: t3
Plumber ure of cen u _ �orstter
Title tter
caty/ToMm of License Number q33�
I Journeyman
i
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION SKETCHES I PROGRESS INSPECTION
FEE
NO.
APPLICATION FOR PERMIT TO DO GASFITTING
i
i
NAME A TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER OR OASFITTER
LIC. NO,
I
PERMIT GRANTED
DATE x_19
GAS INSPECTOR
m Date.. . . .. . .....r. . . .. . ... ..
OE`NORTH 14'
02 �` ° TOWN OF NORTH ANDOVER
ti _� P
' PERMIT FOR GAS INSTALLATION
s •
SACMU5Et
This certifies that . . . . . . . . . . .
has permission for gas_ installation '- �!. . . . . . . . . . . . .
in the buildings of .t : �:_ 'r� ���'�-'� . . . . . . . . . . . . . . . . . . . . . . .
at .�- -{ .� `r ,�IVorth Andover, Mass.
Fee. . . `. . Lic. No..!7 . . . �i..</1�.�.�/�s :!. . . . . . . . .
�r GAS INSPECTOR
41
Check#
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i MASSACHUSETTS UNIFORM APPLICATION FOR'PERMIT TO DO GASFITTING
t or
ype)
'r
Ma$s;� Date 20� Permit j 0�
Building L tion (C// .
wners me
' ype of occupancy
New❑ Renovation❑ Replacement/ Plans Submitted: yes p No
❑
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W u a�
0 m. E
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W ce (D _ o �
= oma = aZ ¢ � LU U5
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SUB-BSMT o o a p. •'
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR.
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
nstalling Company Name
Check one: Certificate
address
❑ Corporation
lusiness Telephone 0' _U ❑ Partnership
lame of Llcensed Plumber.or das Fitter Irmto.
INSURANCE COVERAGE:
"I have a current 11 blilty Insurance policy or its substantial equivalent; which meets the requirement; of MGL Ch 142.
Yes ;75-10 No ❑
If you have checked yes,please Indicate the
type of coverage by checking the appropriate box
A Ilabillty Insurance policy�/ Other type of indemnity ❑ Bond
OWNER'S INSURNACE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter
142 of the Mass.General Laws, and that my signature on s per a
ppiication Waives this requirement;
S gna re o Owner or Owners Agen Check one:
Owner ❑ Agent ❑
iereby certify that all of the details and InFormatlon I have submitted for enteredl In above application are true and accurate to the best of
y knowedge and that all plumbing work and Installations performed under the permit Is e r this appllcation be in compliance with
i pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Zgnre
B Type of License:
By ❑Plumber
Tide ❑t;asfitter of L4censedPu ter or Cas F tter
Ciry/7own
APPROVED(OFFICE USE ONLln License Number
❑Journeyman
BELOW ON OFFICE USE ONLY
FINAL INSPECTIONS 1IET_CNES ` PROGRESS INSPECTIONS
iEE
APPUCATION FOR PERMIT TO 00 PLUMBING
NAME A TYPE OF IMLDMO
LOCATION Of BUILDING
PLUMBER
Pi11MIT GRANTED
DATE .........._...,..19
P MBING MPECTOR